1st AAHIPAA  ions  

HIP Vers 5010 and D 0Versions 5010  and D .0

June  9,  2009

Medicare  Fee  for  Service  t    ions 

Implemen ationof HIPAA Vers 5010  and  D.0

Chris  Stahlecker

Centers  for  Medicare        

and Medicaidof  

ServicesOffice

Information Services

National Provider Education Call

Today’s  Agenda

Medicar e Fee F or Service Medicare Fee For Service Implementation Implementation of of HIPAA v5010 and D.0 Transactions and Code Sets

• Regu al ont  i requirement f trans c ii ts for th th  t onstR l ti e a ti

• Why  change – benefits  of  the  new s tandards

• Gettiing Started d

• Medicare  scope  of  change  and  enhancements

• What  you  can e xpect fr om  your  MAC

• What  are  some  action  steps  you  could  take  now?

2

RegulationRegulation

Reqquirements

3

         What

      

HIPAA Modifications RuleHIPAA Modifications Rule Version 5010 of the X12 standards suite of administrative transactions

Version D.0 of the NCPDP suite for retail pharmacy

Version 3.0 of the NCPD P Suite for Medicaid pharmacy subrogation

Version D.0 or Version 5010 for retail pharmacy supplies and services, based on trading partner agreements

was adopted under the

4

Why  Version  5010?   

Version 4010 is outdated:�

More than 5 years since initial implementation, but 8 yearssince balloting of the current version

� Many Many situational situational and and required required rules rules

did did not not fit fit businessbusiness practices of the industry

�

Industry relied extensively on companion guides, limitingvalue of standards

� Many transactions

Many transactions were were not not implemented implemented at at all all because because of of limited utility and value

Version 5010 is an improvement because it… �� Includes Includes structural structural and and content content oriented oriented

changeschanges� Incorporates more than 500 change requests � Resolves ambiguities in situational rules� Provides more consistency across transactions – most rules

are thhe same thhroughhout thhe suiite�

Shortcomings have been addressed to increase value of transactions such as referrals and authorizations.

5

Why  Version  D.0?  

Version 5.1 is outdated:

�

years s ince balloting of More than 5 years since

the cinitial

urrent versionimplementation, but 8

years since balloting of the current version

Version D.0 is is an an improvement because it:Version D.0 improvement because it:

� Incorporates change requests submitted by the industry to accommodate changing business needs

� Incorporates changes necessitated by the requirements of the Medicare Prescription Drug Improvement and Modernization Act (MMA)

6

Policy  features  of  HIPAA  modifications  rule

Compliance date for 5010 and D.0� Mandatory compliance on January 1, 2012 – all covered entities

Internal Testing to begin on or after January 1, 2010 External testing to begin on or after January 1 2011External testing to begin on or after January 1, 2011

No entity may require another entity to use the new version of the standard without agreement between the two parties for

testing and implementationtesting and implementation

Ability to use X12 or NCPDP for retail pharmacy supplies and services�

Supports existing industry practice�

Supports existing industry practice

Requires agreement between trading partners

Compliance date for Version 3.0� Mandatory compliance � on Mandatory compliance on January 1 2012 all covered entities January 1, 2012 – all covered entities

except small health plans Small health plans have until January 1, 2013

7

Benefits  of  Conversion:  5010/D.0/3.0

Less ambiguity in the TR3 (guides)

as Enhanced as referrals and referrals authorizations

usability and usefulness of certain transactions such and authorizations (X12 and NCPDP)(X12 and NCPDP)

Improved utility of the NCPDP standards, compliance with Part D requirements

Reduces reliance on companion guides

Supports increased use of EDI between covered entitiesSupports increased use of EDI between covered entities

Supports E-Health initiatives now and in the future

Version .3 prov0 id 3 0 ides stV i tandard meth Sthod ofd f recoupid ng t d i Statet Medicaid funds paid inappropriately

8

Getting  Started

Purchase of Implementation Guides and access toTechnical Questions

�

X12: www.x12.org�

g

�

X12 portal: www.x12.org/portal

NCPDP (for D.0 and 3.0): www.ncpdp.org

X12 Responses to Technical CommentsX12 Responses to Technical Comments �

www.cms.hhs.gov/TransactionCodeSetsStands/Other

� Request C hanges to standards: .www hipaa -dsmo org Request Changes to standards: www hipaa dsmo.org � CMS Website for industry wide information:

http://www.cms.hhs.gov

9

Who is   Affected?

• All HIPAA Covered Entities – Providers

Health Plans – Health Plans – Clearinghouses

• Business Associates of Covered Entities that use the affected transactions

• Billing/Service Agents

10

When  are  you  required  to  have  system  changes 

implemented?implemented?

• January  1,  2012 is

tr

  the ansact ons

cut  off  date  for  the  old 

ii

• eM dica bdi re  willill  d t b i tM b e  ready t o b egin t ransitioniti  iing

on     

January 1, 2011

11

What  must  be  changed? • The    currently 

5010 

formatsand from NCPDP 

used mus5.1 to

t D.

be     0

upgraded fr om  X12  Version  4010A1  to 

• Systems eligibility

that 

inquirysubmit 

and r

eclaims,  rec

sponseseive must

rembeittancanaly

ezs, ed

extochaniden

ge tify

claim softw

astatus or 

eligibility  inquiry and responses    re 

andmust be analyzed to identify software and business  process 

changes

• The  new  versions  have  different  data  element  requirements

• Medicare has performed a comparison of the current and new formats for• Medicare  has  performed a   comparison of the current and new formats for the  transactions  used  and  they  can be f o

und  at 

http://www.cms.hhs.gov/ElectronicBillingEDITrans/18_5010D0.asp

• Software  must  be  modified  to  produce  and  exchange  the  new  formats

• Business    y elements 

processesnow requi

ma

red

need  to  be  changed  to  capture  additional  data 

• Transition to the new formats must be coordinated:

– continue

 to 

use 

the 

– start to 

use 

the 

new  current 

formats 

formats  for  some  Trading  Partners’  exchange

 

with other  Trading  Partners

12

Getting  Started

• Medicare  FFS  processes  the f ollowing  ASC  X12  version 4010A1

4010  and 

 

transactions:

nsI t uit tiona  l Cl i (837 I)– I tit ti l Claim  (837‐I)– Professional Claim

– Claim Status

 

   Inquiry 

(837‐P)and Response   

Eligibility 

 

 

(276, 277)

––

Eligibility InquirInquiryy andand RResponseesponse (270,(270, 271)271)Remittanc

e 

 

AdviceTransaction 

(835)– Acknowledg

ement (T

Functional  Acknowledgement  A1)

– (997)

• Medicare  also  processes  DME            Claims in the NCPDP version 5.1

13

Getting  Started

• Medicare  FFS is   well  entrenched    using EDI

– 99.8% of   Medicare  Part A   claims  are  received  in  the  837‐I

– 95.6% of Medicare Part B claims are received in the 837 P95 6% of Medicare Part B claims are received  in  the  837 ‐P

– You  can  find  additional  metrics  on  use  of  our web  EDI  on    page:

http://www.cms.hhs.gov/EDIPerformanceStatistics/

• ThThe Ad i i i Si Administrative  Simplifi i C l A (ASCA)lificat on  i omp ance  ct  (ASCA)  requii C li A ires 

the  use  of  electronic claims for providers to receive Medicare 

reimbursement.

ASCA– ASCA  nE fE cemen   shfor tt hows 68% 68% dd ecrease i l i b i i iiinception

n  paper cl aim  submission  s ince 

• It is  

/critical that

f   the  transition   

d dfr om current 4010A1 formats to the 

5010/D.0 f ormats is   conducte   in a   manner t

hd hat  retains  or  improves upon         

the current rate of EDI

14

Getting  Started

• Medicare  started  early ‐ project  work  began  in  2007 – An  analysis  was  performed  comparing  the  ASC   

ve s

X12 

  4010A1    

of:

and 5010rsion

• Claim  (837‐I,  837‐P,  837‐I  COB,  837‐P  COB)

• Remittance  (835)

•

Claim  Status  Inquiry/Response  (276/277)•

Eligibility  Inquiry//Response  / (270/271)

– An  analysis  was  performed  comparing  the  NCPDP  5.1  and  D.0  formats

–

An  analysis  was  performed  comparing  the  UB04  and  837‐I  COB claim

An ana ys s l i was perf d i th CMS 1500 d th 837 P COB– A l i formed  comparing  the  CMS‐1500  and  the  837‐P  COB claim

– A  side‐by‐side  comparison  of  the  4010A1 and 5010 ASC X12 claim, 

remittance,,  claim  status  and  eliggibility inq

y  uiry/q y re/ s

pponse  rsi

ons as 

ve well        to  D.0  claim 

asthe

NCPDP 5.1 are a vailable  on  the  CMS  web  site:

http://www.cms.hhs.gov/ElectronicBillingEDITrans/18_5010D0.asp

15

HIPAA  5010  Scope • With  5010,  Medicare  also  implements:

– “InfrastructureInfrastructure” preparation for ‐10preparation for ICDICD 10•

Diagnosis  cod

es  require a 

‘Y2K‐like’

  pansion    

e x ofthe

claim

– New  ASC  X12 s tandard  acknowledgement   re   ansactions

andjection

tr – Selected  systems and process enhancements that move  Medicare FF

 

 

 

S processing towards modernization

16

HIPAA  5010  Scope

• New  ASC  X12 s tandard  acknowledgement  and 

rejection  transactions

– The  Functional  Acknowledgement  997 is  being replaced  by  the  999 tr

ansaction

– The       will  

Claims 

Acknowledgement   

(277‐CA) 

be 

used to replace proprietary error reportingused to r eplace proprietary error reporting

17

Enhancements  Included  with  5010 • Enhancements are focused on functional areas requiring 5010 

changes  and 

are  limited  to:

– ImprImproovvinging claims receipt, control, and balancing procedures claims  receipt,  control,  and  balancing procedures 

– Increasing c onsistency of   claims  editing and  error  handling

• Provides c ommon  edit  definitions  to  be  used  by  all  systems and 

jurisdictions

– Returning  claims  needing  correction  earlier in the  process

• Adds  edits  for c ommon  mistakes  to  the fr ont  end  MAC  systems,  er rath  than  waiting  to  do  these 

edits  in  the  adjudication  systems

– Assigning  claim  numbers closer  to  the  time  of  receipt

• The fr ont end systems will assign the base claim number (in the format 

expected 

by 

the adjudic

a

tion syste

m), 

and 

have 

the 

adjudica

tion 

system 

add any 

suffix

 

necessary for 

split or 

adjust

ment

claims

add any suffix necessary for split or adjustment  claims

18

HIPAA  5010  Scope  vs.  ICD‐10  Scope

The  HIPAA  5010  project is  a   pre‐requisite  for  the  ICD‐10  project

• What 5010 DOES do:– Incr

eases 

 

 siz

the field e  for  ICD  codes  from 5   bytes  to 7   bytes

– Adds a one‐digit version indicator to the ICD code to indicate 

version 9 vs.10 –

Incr

eases   

 

the

– Includes some 

number  of  diagnosis  codes  allowed  on aof

      

Medicare FFS

other 

da a

claimthe t  

modifications  in  the s tandards  adopted  by 

• What  5010  DOES NOT do:– Does  not add  pr

ocessing 

needed to use ICD‐10 codes–

Does  not add a

   

crhosswalk of ICD‐9 to 

ICD‐

10 cod

es

– Does  not require t he   o

 

ICD‐10 

f co

d use

f des

The  5010  format  allows  ICD‐9  and/or         

ICD‐10the transaction standard.

CM  &  PCS  code  set  values  in 

The  business rules for using ICD‐10 code set values will be defined with the ICD‐10  

project. 19

What you can expect from What you can expect from

your MAC

20

Medicare  Administrative  Contractor  (MAC)  “Front Ends(MAC) Front Ends”

Each  MAC  runs a  different Front End system at their own local dadattaa  cecentteer,, a nd

 exchan

ges tra

nsact

ions wi

th 

their 

adjudication systa d

e

m e c a ges

running 

att a san actEntoes t

rprise 

Datat e 

Center (EDC)

– MACs  must  update  their  Front  End  Systems’ translator and trading 

partner management system that performs

authentica

tion

validationand excpartner

h

ange manage

of thement syste   st

andarmd 

trthat  performs  authentication, v  

ansactionsalidation

– MACs  must  also  plan  for  and  implement  software  developed  by FISS 

and  MCS  to  perform  detailed  claim  editing  and  numbering  re

ei ,co

and  pt  ntrol balancing for EDC exchanges

candcontrol  and  balancing  for  EDC  exchanges 

– The  project  approach is to upgrade Group 1 MACs first (J1, J3, J4, J5, 

J13  and  CEDI),  and  s

 to 

address 

sub equently

the  MACs  in  transition

– A “ certification”  test       btheir Trans  

will be e xecutedition Phase

yy each  MAC pp rior  to  initiating  g

21

Medicare  Administrative  Contractor  (MAC) Front Ends(MAC)  “ Front  Ends”

• MACs  will c oordinate an information exchange within their 

Jurisdictions  to 

addr

ess:

– Whether a   new  Trading  Partner  (Submitter  ID) will    be r equired

– The  steps  to  transition fr om  the  current  formats  to  the  new 

formatsformats

• Requirements        transaction for testing each

• Testing  procedures per    each transaction

• Clearinghouse   v endor  test  and support

– List  of v endors  who      have completed testing

22

HIPAA  5010 /  D.0  Timeline Begin Medicare FFS

begins accepting1st Quarterly Release Integration for 5010 Changes 5010; 4010A1 for ICD-10 5010 Changes

Testing continues 4010A1 ends Cut-over

DEVELOPMENT SYSTEM TEST TRANSITION

OCT1, 2008 JAN 1, 2009 JAN 1, 2010 JAN 1, 2011 JAN 1, 2012 OCT 1, 2013

23

Upcoming  Communications • CMS will

updat

 develop educational materials and issue progress 

es 

on the 

Medicare Fee‐

for‐Service 

5010 pr

oject to 

our trading 

partner  

s  pr

and oviders.

• Outreach:

– National  Provider  Calls  and  CMS  Open  Door  Forums

– Listservs 

• MAC  provider  listservs  r      (ove 470,000 subscribers)

• 18  unique  FFS  provider  listservs  (131,000  subscribers)

• Dedicated MLNproduct) list

 

serv 

Matters  is   primar    (ov r 31,000

thesubs

ycribers)

FFSe

(this educational 

• Clearinghouse  listserv   subscribers) 

–

(3,303

Provider P artnership  Network (E ‐mail  list  to  over  131  national provider associations and over 2,600 State/local provider associations

 covering 

   

all provider types) 24

Upcoming  Communications – MAC  Web  stings Po

– MAC  ins 

outr

bulleteach 

and n ewsletters, IVR messages, remittance advice, 

activities,,  and  “Ask  the 

Con

tractor”  cal

ls

– Exhibits  at  national  provider c onferences –

Regional  Office  outreach  activities and       

l

FFS providernews etter

Medicare

• Products  include:

– MLN  Matters  National  Articles and Associated News Flash Items– Dedicated  HIPAA  5010/D.0   

(http://www.cms.hhs.

Web

Pag

e

gov/Electro

nicBillingEDITrans/18_5010D0.asp#)–

Downloadable E ducational  Materials (fact sheets, tips sheets, 

brochures, quick reference charts and 

slide 

sets)

brochures quick 

reference charts and– Frequently‐Asked Questions

slide sets)

25

               What

now?now?

• Contact  your    system v endors

– Does your license include regulationDoes your license include regulation updates updates” – Will the   

999?

upgrade include  acknowledgement  transactions  277CA  & 

– WillWill  thethe  upgrupgraadede  includeinclude aa  “ rreeadableadable” errerroorr  rereppoorrtt  prproducedthese

 

277CA and 

999 tr

ansactions? oduced frfrom om 

• Inquire      ar     when they e planning to  upgrade  your  system

– Assess this response to be sure your vendor can assureAssess this r esponse to be sure your v endor can assure your transition well  before  the  cutoff,  Jan 1   2012

your transition

• Evaluate  the  impact  to  your routine 

planning for training, tr

ansition

operations  and  begin 

planning for training transition

are some action steps you could take

26

Questions ?Questions ?

27